This document summarizes information from a presentation about Michigan's Primary Care Transformation Demonstration Project. It discusses care management training requirements, provider requirements including having a qualified care management team, patient eligibility criteria for BCBSM and Medicaid, billing codes and documentation guidelines, metrics that will be measured, and the process for performance-based incentive payments.

1. Michigan Primary Care Transformation
Demonstration Project
Primary Care Physicians and Practice Teams
May 23, 2012

2. Agenda
 Demonstration Project Update
• Care Managers
• Transformation Payments
• Participating Payers
• Process and Outcome Metrics
• Pay for Performance
 Interesting Facts
 Surveys
 Comments on transformation activities in Michigan
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3. Care Management Training
Guidelines
• Services provided by Moderate Care Managers are
billable AFTER Care Managers complete approved
self-management training
• Services provided by Complex Care Managers are
billable AFTER Care Managers have completed
approved Complex Care Management training
• PDCM*-codes should not be billed by untrained
care managers
(PDCM: Provider Delivered Care Management)
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4. Provider Requirements: Care
Management Team
 Individuals performing PDCM services must be
qualified non-physician practitioners employed by
practices or practice-affiliated POs approved for
PDCM payments
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5. Provider Requirements: Care
Management Team
 The team must consist of:
• A lead care manager : RN, LMSW, CNP or PA who has
completed an MiPCT-accepted training program
• Other qualified allied health professionals:
• LPN, LVN, CDE, RD, Nutritionist Master’s Level,
Pharmacist, respiratory therapist, certified asthma
educator, certified health educator specialist
(bachelor’s degree or higher), licensed professional
counselor, licensed mental health counselor
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6. Provider Requirements: Care
Management Team
 Each qualified care team member must:
• Function within their defined scope of practice
• Work closely and collaboratively with the patient’s
clinical care team
• Work in concert with BCBSM, BCN, or other
participating payer’s care management nurses as
appropriate
Note: Only lead care managers may perform
the initial assessment services (G9001)
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7. BCBSM Patient Eligibility
 The patient must have active BCBSM coverage
that includes the BlueHealthConnection® Program.
This includes:
• BCBSM underwritten business
• ASC (self-funded) groups that elect to participate
• Medicare Advantage patients
Services billed for non-eligible members will be rejected with provider liability.
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8. BCBSM Patient Eligibility
 Checking eligibility:
• Eligible members with PDCM coverage will be
flagged on the monthly patient list
• Providers should also check normal eligibility
channels (e.g., WebDENIS, CAREN IVR) to confirm
BCBSM overall coverage eligibility
Services billed for non-eligible members will be rejected with provider liability.
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9. BCBSM Patient Eligibility
 The patient must be an active patient under the
care of a physician, PA or CNP in a PDCM-
approved practice and referred by that clinician
for PDCM services
• No diagnosis restrictions applied
• Referral should be based on patient need
 The patient must be an active participant in the
care plan
Services billed for non-eligible members will be rejected with provider liability.
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10. Recent BCBSM Developments
 All underwritten groups are participating
 Self-Funded groups that have joined:
• URMBT, Zeledyne, Severstal, Magna, Visteon,
Gordon Foods
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11. BCBSM High Deductible Health Plans
 Only members who have a High Deductible Health Plan
with a Health Savings Account will be financially liable
for PDCM services
 To identify the amount of cost share, providers can use
Web-DENIS or CAREN IVR to verify if deductible has
been met
• Amount of payment will vary based on where member is at
in fulfilling their deductible requirement
• Patient cost share can be identified by looking in the
patient liability column, similar to what you would see for
any other patient
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12. BCBSM General Conditions of Payment
 For billed services to be payable, the following
conditions apply:
• The patient must be eligible for PDCM coverage.
 Non-approved providers billing for PDCM services will be
subject to audit and recoveries.
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13. BCBSM General Conditions of Payment
 For billed services to be payable, the following
conditions apply:
• The services must be delivered and billed under the
auspices of a practice or practice-affiliated PO
approved by BCBSM for PDCM reimbursement.
• Based on patient need
• Ordered by a physician, PA or CNP within the approved
practice
• Performed by the appropriate qualified, non-physician
health care professional employed or contracted with
the approved practice or PO
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14. BCBSM Billing and Documentation:
General Guidelines
 The following general billing guidelines apply to
PDCM services:
• Approved practices/POs only
• Professional claim
• 7 procedure codes
• PDCM may be billed with other medical services on
the same claim
• PDCM may be billed on the same day as other
physician services
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15. BCBSM Billing and Documentation:
General Guidelines
• No diagnostic restrictions
• All relevant diagnoses should be identified on
the claim
• No quantity limits (except G9001)
• No location restrictions
• Documentation demonstrating services were
necessary and delivered as reported
• Documentation identifying lead CM isn’t
required, but documentation must be maintained
in medical records identifying the provider for
each patient interaction
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16. PDCM Codes
CODE SERVICE
G9001 Initial assessment
G9002 Individual face-to-face visit (per encounter)
98961 Group visit (2-4 patients) 30 minutes
98962 Group visit (5-8 patients) 30 minutes
98966 Telephone discussion 5-10 minutes
98967 Telephone discussion 11-20 minutes
98968 Telephone discussion 21+ minutes
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17. BCN PDCM Payment Policy
 BCN will pay the lesser of provider charges or
BCN’s maximum fee
• CNPs or PAs paid at 85%
 No cost share imposed on members
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18. BCN General Conditions of Payment
 For billed services to be payable, the following
conditions apply:
• The patient must be eligible for PDCM coverage.
• The services must be delivered and billed under
the auspices of a practice or practice-affiliated
PO approved by BCN for PDCM reimbursement.
• Billed in accordance with BCN billing
guidelines
 Non-approved providers billing for PDCM services
will be subject to audit and recoveries.
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19. BCN Patient Eligibility
 Provider panels are available through Health e-
Blue web
 The patient must be an active patient under the
care of a physician, PA or CNP in a PDCM-
approved practice No diagnosis restrictions are
applied
• Order for PDCM should be based on patient need
 The patient must be an active participant in the
care plan
Services billed for non-eligible members will be rejected with provider liability.
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20. Medicaid Patient Attribution
 Medicaid managed care population only
 Attributed member:
• Medicaid beneficiary enrolled in a Medicaid Health
Plan AND
• assigned Primary Care Provider is affiliated with
participating practice/PO

21. Enrollee Lists
• Attribution process occurs on the first business day of
the month
• Medicaid enrollee lists submitted to Michigan Data
Collaborative (MDC)
• MDC will post enrollee lists on MDC secure site for
retrieval by PO
– Automated message from MIShare at UMHS
– mlawr@med.umich.edu
– gwenthom@med.umich.edu
• PO responsible for transmitting enrollee lists to
practices

22. Medicaid Payment Calculation
 Medicaid payments calculated as Per Member Per
Month (PMPM) based on monthly attribution
counts:
• $1.50 PMPM Practice Transformation paid to
Practice
• $3.00 variable payment based on performance paid
to PO

23. Provider Enrollment
Required for Payment
 PO’s will be enrolled as an MCO in CHAMPS
system by DCH.
 Practices must enroll as either an individual sole
proprietor or as a group in Medicaid CHAMPS
system.
 PO Enrollment questions: landfairt@michigan.gov
 Provider Enrollment questions: 800-292-2550

24. Payment Timing
• Quarterly EFT payments appear as gross adjustment
• Reconcile payment amount with your enrollee list
• Payments released mid month after end of the
quarter
– April (QTR 1)
– July (QTR 2)
– October (QTR 3)
• Regularly check the Payment Update Tab on
MIPCTdemo.org for new/updated information
• Payment questions: landfairt@michigan.gov

25. UMHS CMS Payment Processing and
Distribution to POs
 CMS does not have a mechanism to pay POs directly
individual line item remittances to UMHS (as they did
for practice transformation to the practices).
 Though not ideal, CMS will not change their practice –
thus UMHS must receive, reconcile and then
distribute payments
 Work is underway and a front-end application has
been built to:
- Reconcile claims with member lists
- Calculate PO payments

26. UMHS CMS Payment Processing and
Distribution to POs
 This will result in a payment delay for the first set of
care coordination payments. Goal is to distribute to
POs by early June. Earlier if at all possible.
 Afterward UMHS will work to get on a regular cycle of
payment distribution.

27. Interesting Facts…
 18 MNO PCMH currently participating in MiPCT
 35 Primary Care Physicians one referral physician co-
located in PCP PCMH
 Participation continues as long as PCMH designation
is maintained
 Two practices are being reviewed by BCBSM
 Attributed/Assigned population varies monthly
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28. Interesting Facts: E&M Uplift
 Four physician family practice: $91,654
 Four physician pediatric practice: $68,546
 Two physician adult practice: $48,929
 Solo family physician: $10,984
 Average amount: $11,777
 Medical Network One PCMH: $412,197
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29. Interesting Quality Scores
 7 PCPs with poor quality and cost scores de-
participate
 PCP highest aggregate quality score
• Anchor Bay Clinic: 78.50%
• Macomb Pediatrics: 85.92%
 PCP lowest aggregate quality score
• Adult medicine: 42.10%
• Pediatrics: 20.00%
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30. Interesting Quality Scores 2011*
 BCN Average 71.36%
 BCBSM Average 68.02%
(MiPCT PCP cohort)
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31. Metrics
 Six months:
• Patient registry
• After hours access
• Moderate Care Managers hired, trained and working
• Complex Care Managers hired, trained and working
• Moderate/Complex Care Managers=Hybrid Care Managers
• HEDIS Specific Clinical and Process Measures
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32. Diabetes
 Ages 18-75 Type 1 or 2
1. A1C
2. Poor Control A1c>9
3. Control A1c< 8
4. LDL-C Test
5. LDL-C Controlled < 100 mg/dl
6. BP <140/90
7. Retinal Eye Exam
8. Nephropathy Screen or Evidence of Nephropathy*
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33. Asthma
 Self-Management Plan
 Asthma Action Plan
(ages 5-50) Non HEDIS
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34. Performance Incentive Payment
Process
 Health plans contribute $3.00 PMPM to the
incentive program pool
 Metrics are assessed every six months and points
are calculated for each PO
 POs are ranked by total points and grouped into
payment categories
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35. Performance Incentive Payment
Process
 Entire pool is paid out in variable amounts based
on ranking
 PO retains the agreed upon percentage 20%
 PO distributes 80% to the PCMH
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36. Issues
in 3 x 5
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